MEDIATOR APPLICATION FORM PAGE 3 d. Areas of Expertise and Experience in Each Area PLEASE ENTER THE ESTIMATED NUMBER OF MEDIATIONS FOR EACH TYPE: Antitrust/Trade Regulation Auto Tort – Personal Injury/Property Damage/Wrongful Death (PI/PD/WD) Auto Tort – Uninsured Motorist – PI/PD/WD Bankruptcy Civil Harassment Construction Defect Contract – Breach of Rental/Lease Contract (not insurance, UD, or wrongful eviction) Contract – Collections Contract – Contract/Warranty Breach – Seller Plaintiff (not insurance, fraud, or negligence) Contract – Contractual Fraud Contract – Insurance Coverage/Subrogation Contract – Negligent Breach of Contract/Warranty (not insurance or fraud) Contract – Tortious Interference Declaratory Relief Only Elder/Dependent Adult Abuse Employment Employment – Wrongful Termination Family – Custody Injunctive Relief Only (not domestic/harassment) Non-PI/PD/WD Tort – Business/Commercial Tort (not fraud or breach of contract) Non-PI/PD/WD Tort – Civil Rights (e.g., discrimination, false arrest) Non-PI/PD/WD Tort – Defamation (e.g., slander, libel) Non-PI/PD/WD Tort – Fraud (no contract) Non-PI/PD/WD Tort – Intellectual Property Non-PI/PD/WD Tort – Legal Malpractice Other PI/PD/WD Tort – Asbestos Other PI/PD/WD Tort – Intentional (e.g., assault, vandalism, etc.) Other PI/PD/WD Tort – Intentional Infliction of Emotional Distress Other PI/PD/WD Tort – Medical Malpractice Other PI/PD/WD Tort – Premise Liability Other PI/PD/WD Tort – Product Liability (not asbestos, toxic/environmental) Partnership & Corporate Governance Probate – Trust/Wills Probate – Conservatorship Real Property Real Property – Mortgage Foreclosure Real Property – Eminent Domain/Condemnation/Zoning Real Property – Quiet Title Real Property – Unlawful Detainer Securities Toxic Tort/Environmental Workplace Harassment Writ of Mandate Other e. Awards ORGANIZATION AWARD (DESCRIPTION) DATE ORGANIZATION A AWARD A AWARD DATE A ORGANIZATION B AWARD B AWARD DATE B ORGANIZATION C AWARD C AWARD DATE C f. List any languages other than English in which you can conduct mediation SECTION IV REFERENCES List 3 persons who are familiar with your mediation skills NAME ORGANIZATION PHONE NUMBER EMAIL ADDRESS NAME A ORGANIZATION A PHONE # A EMAIL A NAME B ORGANIZATION B PHONE # B EMAIL B NAME C ORGANIZATION C PHONE # C EMAIL C SECTION V ETHICAL CONSIDERATIONS I. I here certify that: a. No disciplinary action has ever been taken against me by any state, federal, or professional licensing board/agency. b. I have not been convicted of a felony or misdemeanor at any time in the past. c. If applicable, I am an active member in good standing with the State Bar of California. If not, please explain. Name: Date: Signature: II. I hereby certify that I have read, and will abide by, the Ethical Standards used in Court mediation programs as stated in the California Rules of Court, Chapter 3, Articles 1 and Article 2. Name: Date: Signature: III. I understand that if accepted to the panel that I may be required to provide volunteer services to educate the public about mediation as an alternative to litigation and when appropriate I may offer mediation to those who qualify without charge. IV. I hereby certify that the foregoing is true and correct to the best of my knowledge. Name: Date: Signature: PLEASE UPLOAD A RECENT PHOTO OF YOURSELF: CHOOSE FILE(S) PLEASE UPLOAD A SHORT BIO OF YOUR MEDIATION SERVICES - NO MORE THAN 200 WORDS - TO POST ON THE MCLA WEBSITE: CHOOSE FILE(S) SUBMIT ► Please allow a few seconds for the form to SUBMIT.